Provider Demographics
NPI:1760680300
Name:PONEMAH CLINIC
Entity Type:Organization
Organization Name:PONEMAH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF COOR.
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3912
Mailing Address - Street 1:HWY 1
Mailing Address - Street 2:BOX 497
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1
Practice Address - Street 2:BOX 497
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service